LIVER ECHOTEXTURE -

A METHOD TO IMPROVE

INTERPRETATION

ACR ANNUAL MEETING 2018

BRAHEE D

KLEPCHICK P

THOMPSON D

THE AUTHORS HAVE NO DISCLOSURES

LIVER ECHOTEXTURE

INTRODUCTION

Ultrasound (US) is a commonly used diagnostic tool in the

evaluation of the liver and is the most highly recommended imaging

modality used in evaluation of suspected liver disease [1]

However as it is largely subjective characterizing liver echotexture

is often difficult for radiologists with limited experience [2]

There have been few studies in the literature demonstrating

techniques for evaluating liver parenchyma echotexture

characteristics and a consistent measurement method has not been

established [3456]

LIVER ECHOTEXTURE

OBJECTIVE

To determine if specific

training in interpretation of

liver US utilizing comparison

to the spleen and a practice

tutorial will improve

interpretation agreement

and diagnostic confidence in

new radiology residents

LIVER ECHOTEXTURE

METHODS

A retrospective review was performed of 64 abdominal

US examinations in adults (with representative cases

of both normal and abnormal liver echotexture) imaged

between 07012014 and 07012015

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

BRAHEE D

KLEPCHICK P

THOMPSON D

THE AUTHORS HAVE NO DISCLOSURES

LIVER ECHOTEXTURE

INTRODUCTION

Ultrasound (US) is a commonly used diagnostic tool in the

evaluation of the liver and is the most highly recommended imaging

modality used in evaluation of suspected liver disease [1]

However as it is largely subjective characterizing liver echotexture

is often difficult for radiologists with limited experience [2]

There have been few studies in the literature demonstrating

techniques for evaluating liver parenchyma echotexture

characteristics and a consistent measurement method has not been

established [3456]

LIVER ECHOTEXTURE

OBJECTIVE

To determine if specific

training in interpretation of

liver US utilizing comparison

to the spleen and a practice

tutorial will improve

interpretation agreement

and diagnostic confidence in

new radiology residents

LIVER ECHOTEXTURE

METHODS

A retrospective review was performed of 64 abdominal

US examinations in adults (with representative cases

of both normal and abnormal liver echotexture) imaged

between 07012014 and 07012015

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

INTRODUCTION

Ultrasound (US) is a commonly used diagnostic tool in the

evaluation of the liver and is the most highly recommended imaging

modality used in evaluation of suspected liver disease [1]

However as it is largely subjective characterizing liver echotexture

is often difficult for radiologists with limited experience [2]

There have been few studies in the literature demonstrating

techniques for evaluating liver parenchyma echotexture

characteristics and a consistent measurement method has not been

established [3456]

LIVER ECHOTEXTURE

OBJECTIVE

To determine if specific

training in interpretation of

liver US utilizing comparison

to the spleen and a practice

tutorial will improve

interpretation agreement

and diagnostic confidence in

new radiology residents

LIVER ECHOTEXTURE

METHODS

A retrospective review was performed of 64 abdominal

US examinations in adults (with representative cases

of both normal and abnormal liver echotexture) imaged

between 07012014 and 07012015

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

OBJECTIVE

To determine if specific

training in interpretation of

liver US utilizing comparison

to the spleen and a practice

tutorial will improve

interpretation agreement

and diagnostic confidence in

new radiology residents

LIVER ECHOTEXTURE

METHODS

A retrospective review was performed of 64 abdominal

US examinations in adults (with representative cases

of both normal and abnormal liver echotexture) imaged

between 07012014 and 07012015

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

METHODS

A retrospective review was performed of 64 abdominal

US examinations in adults (with representative cases

of both normal and abnormal liver echotexture) imaged

between 07012014 and 07012015

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

METHODS

Eighteen physicians (Reviewers) were grouped by

level of Radiology training Novices (1st year

Residents) Intermediate (3rd ndash 4th year Residents) and

Expert (Attending Radiologists who routinely interpret

US)

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

METHODS

Each Reviewer was asked to review 64 randomized

abdominal US images to rate the echotexture

characteristics of the liver as homogeneous or

heterogeneous and record their diagnostic confidence

level using a 5-point Likert scale

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

METHODS

Six weeks later Reviewers participated in a liver

echotexture tutorial which demonstrated use of the

spleen as an internal reference and after

approximately 4 additional weeks the same 64 scans

were newly re-randomized and re-reviewed

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

RESULTS

A total of 2304 abdominal US case reviews were

performed A consensus of the Experts in this study

with an intra-rater reliability ICCgt08 formed the

basis for an accuracy standard

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

RESULTS

Using a

quadratically

weighted kappa

there was

significantly greater

agreement

between the Novice

group and Expert

consensus after the

tutorial (p = 004)

than before

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

RESULTS

Using a weighted kappa to measure agreement all of

the 9 Novice Reviewers were in ldquofairrdquo to ldquopoorrdquo

agreement (kappa lt40) with Expert Consensus

before the liver echotexture tutorial

After the tutorial 5 of the 9 in the Novice group

improved to ldquomoderaterdquo agreement (kappa gt40) with

Expert Consensus

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

RESULTS

By intraclass correlation coefficient (ICC) analysis

before the tutorial none of the Novice Reviewers had

ldquogoodrdquo agreement with a consensus of Expert

Reviewers (ICC for all Novices lt60)

After the tutorial 3 of the 9 in the Novice group were

in ldquogoodrdquo agreement (ICC ge 60) with Expert

Consensus

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

CONCLUSION

When characterizing liver echotexture on US the use of the spleen as an internal comparison improves interpretation consensus and confidence in Novice and Intermediate level radiology residents as demonstrated in this preliminary study

Also a tutorial to demonstrate how to apply this principle is useful

This technique should be considered as a training tool for inexperienced US readers

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

LIVER ECHOTEXTURE

IN SUMMARY

When evaluating the echotexture of the liver

parenchyma comparing to that of the spleen

improves resident interpretation and confidence as

well as leads to more consistent agreement with

attending (Expert) interpretations

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069

REFERENCES 1) Tchelepi H1 Ralls PW Radin R et al Sonography of diffuse liver disease J Ultrasound Med 2002 Sep21(9)1023-

32 quiz 1033-4 PMID 12216750

2) Lee CH Choi JW Kim KA et al Usefulness of standard deviation on the histogram of ultrasound as a quantitative

value for hepatic parenchymal echo texture preliminary study Ultrasound Med Biol 2006 Dec32(12)1817-26 PMID

17169693

3) Soresi M Giannitrapani L Cervello M et al Non invasive tools for the diagnosis of liver cirrhosis World J

Gastroenterol 2014 Dec 2820(48)18131-50 doi 103748wjgv20i4818131 PMID 25561782

4) Taylor KJ Riely CA Hammers L et al Quantitative US attenuation in normal Liver and in patients with diffuse liver

disease importance of fat Radiology 1986 16065-71

5) Yao W Zhao B Zhao Y et al Ultrasonographic texture analysis of parenchymatous organs by the four-

neighborhood-pixels algorithm clinical experiment J Ultrasound Med 2001 May20(5)465-71 PMID 11345103

6) Nishiura T Watanabe H Ito M et al Ultrasound evaluation of the fibrosis stage in chronic liver disease by the

simultaneous use of low and high frequency probes Br J Radiol 2005 Mar78(927)189-97 PMID 15730982

7) Altman DG Practical statistics for medical research London Chapman and Hall 1991

8) Cicchetti DV Guidelines criteria and rules of thumb for evaluating normed and standardized assessment

instruments in psychology Psychological Assessment 1994 6(4) 284-90

9) Cohen J A coefficient of agreement for nominal scales Educational and Psychological Measurement 1960 2037-

46

10) Barr RG Ferraioli G Palmeri ML et al Elastography Assessment of Liver Fibrosis Society of Radiologists in

Ultrasound Consensus Conference Statement Ultrasound Q 2016 Jun32(2)94-107 PMID 27233069